No baseline comparison, no deficit exam, no skilled rationale.
The post-stroke model note in §3: the deficit exam by extremity with the comparison to the prior value, swallowing/precautions, and the reason daily neuro observation was required.
“Alert and oriented.”
For a stroke resident, no focal exam or trajectory.
“A&O×3, mild residual expressive aphasia improving, left-arm 4/5 (from 3/5), no new deficit; swallowing safe on the ordered texture.”
“Had a seizure.”
No type, duration, post-ictal state, or notification.
The seizure documentation should capture type/duration/post-ictal recovery, precautions, medication, SBAR, and reassessment.
